Back Pain Myths Closing Sale Everything must go

Everyone knows all about low back pain. This is probably by virtue of the fact that most of us have or will experience it at some stage. Everyone is an expert, clinicians and patients alike and there are a whole host of accepted truths about back pain that we all cling on to. Ideas that replicate themselves successfully across populations have been called memes. Successful memes spread like wildfire and become deeply entrenched. But truth is not necessarily a requirement for the successful meme….

A good example of one of these is that prolonged sitting can cause back pain. For years we have believed that the load placed on the spine may damage intervertebral discs (and other structures) and be a cause of pain. The evidence for this appears not to stack up, and it would seem that even our ideas of an ideal sitting posture are not entirely realistic. But to really kick this particular meme into the bin of back pain myths comes a cracking systematic review published in the Spine journal by Darren Roffey and his colleagues from Ottawa. They found strong and consistent evidence of no association between occupational sitting and low back pain and reasonable evidence that there is no dose-response relationship between sitting at work and back pain. In a separate review they found pretty much the same thing for occupational walking and sitting.

So perhaps it is time to stop fussing about sitting posture in back pain or many of the other biomechanical obsessions that we tend to embrace. At a conference a hung-over colleague of mine once grumbled that the mountain of back pain research hasn’t got us very far. I think that’s not quite right; we have learned loads about what isn’t true and the great thing about deconstructing what we think we know is that it opens the doors to developing fresh models of back pain to test.

So I have a challenge for the Body in Mind readership: what back pain myths can you think of that are ripe for some critical attention? I think this discussion could be a lively affair!

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The one I seem to hear all the time goes something like “It’s probably all those years of lifting incorrectly and wearing my back out”. Oh, and for those who exercise “I never was any good at stretching after exercise”.

nice review here …..Eyal Ledermans papers are brilliant regarding deconstruction of the structural paradigms of the core and other issues …….haven’t time to comment now but the issues regarding cultural obsessions with biomechanics , stability of the core etc appear to be more machine metaphor based than on any biological reality .This is a cultural issue, not just in back pain?

Thanks for the mention Ian. I think part of the problem is that we tend to look for explanations in terms of the things that we can easily see or measure. Structural abnormalities, core strength and postural asymmetries can be seen or measured (or at least we think we can measure them) so these are the variables that have received the most focus in explaining pain. It’s like that Nasruddin story – a man is looking for his car keys under the streetlight even though he knows he lost them in the dark alley. When asked why he says – because the light is better here!

‘the great thing about deconstructing what we think we know is that it opens the doors to developing fresh models of back pain to test’.

Neil, I wonder if you have any ideas of what these may be? I am not playing devils advocate but almost every biomedical approach does not seem very promising so far ? I have a lot of time for Hadlers views on the whole area of pain and his book Stabbed in the back seems a good place to start .
The BPS model as Bronnie mentions on her blog invariably misses out cultural considerations. To many, culture seems to imply ergonomic and work related issues but not often do the wider societal values get considered.David Morris considers these issues in his well written books see here for example http://www.ucpress.edu/book.php?isbn=9780520226890 Iona Heath reviewed this a while back in the BMJ if you have access to it.
I think a degree of acceptance is needed . Back pain is part of the human condition .The over treatment of it is a very recent phenomenon and now a whole industry is built around it. Perhaps this will be harder to deconsruct than beliefs about causes?

neil o'connell Reply:June 17th, 2010 at 12:22 am

Hi Ian,

Tough question. I kind of err towards the idea of putting chronic back pain in the “central pain syndrome” category. This in itslef is not without problems as all of the evidence for abnormal central pain processing is cross-sectional and may be epiphenomena. Of course none of this gives us a working model of acute back pain.

The other possibility is that we are looking at a complex social phenomena as you imply that is not helped by a culture of pseudoexplanations and existing attempts at treatment. I am reminded of 2 choice quotes from back pain epidemiologists here:
Heiner Raspe:

“It is a promising hypothesis that de-medicalization of non-specific back pain may eventually lead to less overall suffering, chronification and social disability than all of the medical, both diagnostic and therapeutic, interventions that are currently employed”

Rachelle Buchbinder:

“The major challenge facing clinicians today may now be how to avoid unhelpful and potentially harmful treatment, rather than selecting the optimal approach”.

Jono Stephens Reply:June 17th, 2010 at 9:55 am

Just to pick your brains…

What would your best guess be for the mechanism(s) of acute or episodic back pain?

neil o'connell Reply:June 18th, 2010 at 5:40 pm

Hi Jono,

Its a tough one. I think it remains reasonable to suspect that most acute/ recurrent non-specific back pain is a response to the threat of, or probably more commonly actual tissue injury/ inflammation. But beyond that diagnostics currently can seem an exercise in value judgements, “expertise” often based on flawed principles, and creative thinking. It seems to be the case that the best thing that people can do in response is to not worry and stay active (and I am a big fan of pain control early with analgesics).

As discussed above the “meaning” of back pain and its medicalisation all feed in to the experience and probably the outcome. But there is a question – why does back pain specifically have this impact over other innoccuous tissue injuries? These unhelpful cultural beliefs that you hear daily in clinic must have a source.

My personal (anecdotal – therefore completely unreliable) experiences of acute and episodic low back pain are that it has a unique quality and when you have your first episode it feels dramatic, disabling and quite frightening (that “I can’t move feeling is a real winner”). Even knowing what I know now an acute bout of back pain will have this hardenened skeptic thinking about discs and joints – it is a powerful model and you just can’t help yourself. So easy to get sucked in to the fear of structural damage even when you spend yer life teaching the opposite. Maybe that “I can’t move” quality coupled with the fact that you can’t see it to check its not swollen, out of place etc has a role. How speculative am I?!

Two very good statements the most pragmatic being the second one as there is large scale medicalisation in many aspects of medicine I feel. People expect things to be done and for treatment acts to be medical and in many cases biomechnical. The challenge clinically is to fulfill expecations without making things worse.
I am a luddite and I feel that if people had consistent care (with the same messages)from the same GP who knew the background and family coping strategies than many unnecessary medical investigations would be eliminated. However , I do feel some of this is both cultural and philosophical since pain for most has to be a ‘structural sensation’ and the experience is not considered too well . What happens is that the complaint of pain is considered to be signs of wosening physiology or pathology and dealt with a rising pharmacological or medical hierarchy.
Too much in my opinion is done to people without understanding them as people . The back pain is often part of a complex multifactoral problem. This may be explained by central pain mechanisms but as you suggested this may be an epiphenomena.. I favour the latter view myself and think there are limits to neuroscience and physiological models! This is why I am going to the British Pain Society meeting in a few weeks on culture and pain –will let you know !

Since we’re all dispensing advice, how about these sacred cows/myths:
“people with back pain can’t turn on their transversus abdominus”
“Transversus abdominus is different to other muscles, and you only need to look at one side to tell what the other side is doing”
and my personal favourite
“There is no actual pathology in low back pain, and it’s probably all in your mind, so forget about looking for any pathology/ies (because we tried and couldn’t find anything)”

DO YOU HAVE BACK PAIN and live in Sydney?

or you do not currently have any pain conditions?
We are looking for people to take part in a study to help us understand more about the process of recovery from back pain.
We need to recruit two groups:
(1) People with recent onset of back pain lasting less than 3 weeks
(2) People who do not currently have back pain
You will be asked to undertake three assessments (approximately 2 hours each) over 4 months at the Physiotherapy Research Lab in the Centre for Physical Health at Macquarie University in Sydney.
You will receive $30 for each assessment to compensate you for your travel and your time involved in participating.
If you are interested and to register please visit our website or contact Dr Julia Hush.

Lorimer is coming to York!

In this first course in the UK for several years, Lorimer will lead you through his 'highlights of pain' tour, visiting the conceptual underpinnings of modern pain rehabilitation, cutting edge pain-related cognitive and clinical neuroscience, critical pain-related thinking, clinical reasoning and treatment principles.

From Painful Yarns, to Explaining Pain Better, to Biologically Based Graded Exposure, the Cortical Body Matrix and the Imprecision Hypothesis, it will be intense, but it will also be scientifically sound, evidence based, clinically applicable and fun!
WHEN: 20 – 21 May 2015
WHERE: National Science Learning Centre, University of York
Reserve your place: joanna@noigroup.com, phone +44(0) 1904737919

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